Mass Exodus of State Health Department Deputies and Senior Management Threatens Institutional Stability

Recent evidence has shown that state health officials typically have relatively short tenures as leaders of state public health agencies, with a median of three years.¹ Rapid turnover of state health officials underscores the critical roles that senior managers in state public health agencies play in maintaining agency stability and leadership during tumultuous periods of uncertainty. Frequent departures of agency heads mean that the deputy health officers and other senior managers are often the keepers of institutional memory, expertise, and experience—and find themselves inserted into policymaking positions when leadership has been vacated. They also play a critical role in training and onboarding newly appointed state health officials who often come from outside of public health practice to lead state public health agencies and need substantial support given the steep learning curve of the transition to their new responsibilities.

Previous studies of the public health workforce have indicated that as much as 42% of the overall workforce plans to retire or leave their organizations by 2020.² Because of this uncertainty and the importance of senior managers and executives to state public health agencies, it is worth exploring retirement plans specifically among established senior leaders and the institutional consequences of a mass exodus. In this editorial, we propose several recommendations to mitigate the untoward ill effects that high levels of abrupt departure may precipitate. This information can be used proactively as an actionable framework to address these pending gaps strategically.

AN EXPERIENCE GAP LOOMS

In this issue of AJPH, Sellers et al. (p. 674) report on several facets of the 2017 Public Health Workforce Interests and Needs Survey (PH WINS) of state and local employees, including manager and senior executive planned retirement by 2023 and the years of experience in their position that would be lost as a result of departure.

Managers and executives constitute 14% of the state public health agency central office workforce, represent 10% of the total workforce, and are a diverse group. About 66% are female, 36% are people of color, and 83% are older than 40 years. These staff are among the most seasoned in the health department having more than 13 years of experience on average, with 7 years in their current leadership role, twice the tenure of state health officials. Yet these leaders are also among the most likely to say that they are planning retirement.

Data from PH WINS show that among managers and executives employed in state public health agency central offices, approximately one third say that they plan to retire by 2023 (Table 1). The estimated 2200 managers and executives who say that they are planning to retire account for about 52 000 years of experience, about 41% of the total years of experience for all managers and executives at state health agency central offices in the United States. This is similar for local health departments—an estimated 3500 managers and executives who are planning to retire (29% of total) account for 86 000 years of experience, about 39% of all local managerial or executive years of experience. This mass exodus compares with 21% for all other health department staff planning to retire by 2023. As Figure A (available as a supplement to the online version of this article at http://www.ajph.org) shows, alarmingly, nine state public health agency central offices have 40% or more of their leadership planning to retire by 2023, whereas 19 have 30% to 39% planning to retire by 2023.

TABLE 1—

Percentage of US State and Local Governmental Public Health Managers and Executives Planning to Retire by 2023: The 2017 Public Health Workforce Interests and Needs Survey

	State Public Health Agencies—Central Office		Local Health Departments
	Manager/Executive, % (95% CI)	All Other, % (95% CI)	Manager/Executive, % (95% CI)	All Other, % (95% CI)
Regions 1 & 2	36 (31, 41)	24 (22, 25)	25 (4, 72)	29 (20, 39)
Region 3	29 (26, 32)	22 (19, 25)	32 (28, 35)	22 (19, 26)
Region 4	29 (23, 35)	19 (16, 23)	30 (26, 35)	22 (21, 22)
Region 5	30 (25, 35)	23 (22, 24)	25 (13, 41)	19 (17, 20)
Region 6	33 (27, 39)	24 (23, 25)	35 (28, 44)	21 (19, 23)
Region 7	25 (15, 38)	24 (22, 26)	20 (9, 39)	14 (9, 20)
Region 8	30 (26, 34)	16 (14, 18)	29 (19, 40)	15 (11, 20)
Region 9	40 (35, 45)	24 (23, 25)	34 (27, 41)	21 (19, 22)
Region 10	29 (29, 30)	17 (17, 18)	25 (15, 37)	17 (15, 19)
National total	32 (29, 34)	21 (20, 22)	29 (23, 36)	21 (19, 23)

Note. CI = confidence interval.

REVERSING THE TIDAL WAVE

All these data indicate that we will see significant levels of planned retirement of experienced senior public health officials in the coming years. Their departure threatens to destabilize organizational leadership as well as the support and onboarding of new executives, positions that experience substantial churning and depend on seasoned professionals to ensure that health departments operate efficiently. Moreover, these senior leaders are a major component of institutional memory, knowledge, and experience—qualities sorely needed when organizations face crises internally and externally (e.g., disease outbreaks, prolonged natural disasters that affect health).

With public health yet to fully address the disarray first noted in the 1988 Institute of Medicine seminal report, The Future of Public Health,³ the documented short tenure of state health officials coupled with precipitous planned retirement rates of higher-level executives present a narrative that is the very essence of a slowly unfolding disaster. Following the specter of the aftermath of the 2007 to 2009 Great Recession, the public health enterprise is far from recovered—budgetary rollbacks and personnel layoffs have taken a devastating toll on capacity and capability.^4,5 Now is not the time to heap leadership challenges on top of the full plate of adversity facing public health agencies.⁶ In short, we are at a crossroads, one in which the path forward cannot be the road that brought us to this juncture. Efforts to retain senior management leaders should be initiated posthaste, even as further work explores the root causes underlying the potential loss of valuable institutional knowledge. Concurrently, substantial national investment in promoting a succession pipeline program should get under way, reinvigorating leadership training and workforce development programs mothballed in recent poor economic times. The loss of the Centers for Disease Control and Prevention–funded National Public Health Leadership Institute in 2011 as a major leadership development initiative serving the broader field could not have happened at a more inauspicious time.

Senior public health leadership roles are high-pressure, low-reward positions, and although they are personally fulfilling for many, they are frequently fraught with peril amid political brinksmanship. Do we dare offer radical approaches to the predictable shortfalls in leadership that we face? We must

• Invest in the future leadership pipeline through educational incentives and scholarships for master of public health and doctoral degrees. This proposed “GI Bill” for public health addresses multiple concerns—the lack of formal public health training within public health practice,² preparing future leaders with strong public health grounding, and filling knowledge gaps among the workforce within specific content shortage areas.

• Establish new federal positions for senior management under the auspices of the Public Health Service or US Department of Health and Human Services, which could be deployed to states and local health departments as needed, allowing for portability, accountability, professionalism, and clear career paths. Executives and other public health staff would remain employed within their respective state systems. Within individual states, personnel rules may require modification to allow for this “deputizing” of federal workers.

• Incentivize senior public health managers to temporarily suspend their retirements. One option deployed in several states is a deferred retirement option plan that allows those reaching retirement age to remain within the workforce for several years while being technically “retired” with pension benefits accruing in 401K-type accounts. This offers the dual benefits of keeping experienced leaders in their valued roles longer and actually saving states money because they no longer contribute to the employee’s retirement plan—the employee is technically already retired—while enabling the worker to accumulate a substantial retirement nest egg.

• Resurrect previously successful national- and state-level public health leadership programs to ensure that a critical mass effect is achieved. Although state and local health officials still have similar programs in operation, few programs remain that benefit the pipeline and future leaders, especially ones that engage senior deputies as mentors. These efforts also need to be focused on developing the health departments of the 21st century, which will include a diverse workforce with highly technical skills that may differ dramatically from areas of current emphasis. Enabling leadership is the first of the requisite components of “Public Health 3.0,” in which the future public health leader takes on the role of the chief health strategist “capable of mobilizing community action to affect health determinants beyond the direct reach of their agencies.”⁷

This is not an exhaustive list of possible remedies, nor is it intended to be. Yet failing to act in novel or thoughtful ways leads us back to the age-old maxim that every system is perfectly designed to give the results it does. It is well past time to marshal the forces of system redesign.